Healthcare Provider Details

I. General information

NPI: 1770715021
Provider Name (Legal Business Name): JENS MITTLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 08/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 JONATHAN LUCAS ST CSB 409
CHARLESTON SC
29425-8900
US

IV. Provider business mailing address

96 JONATHAN LUCAS ST CSB 409
CHARLESTON SC
29425-8900
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-8358
  • Fax: 843-792-8596
Mailing address:
  • Phone: 843-792-8358
  • Fax: 843-792-8596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberLL32094
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: